On the Record with Dr. Seonaid Nolan

Q&A with Dr. Seonaid Nolan, physician lead for addiction medicine at St. Paul’s

Since 2007, Canadian health care providers, addiction experts and social workers have been calling on regulatory bodies to lift barriers that limit access to Suboxone, a substitute opioid used to counter opioid addiction.   

Suboxone, a combination of two medications — buprenorphine and naloxone, has been used to treat opioid dependence in countries such as France, U.S., U.K. and Australia for many years, even replacing methadone as the first-line medication for opioid replacement therapy.

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On July 1, the B.C. College of Physicians and Surgeons lifted a restriction, which will allow all doctors to prescribe Suboxone, making the drug more accessible to addicts.

Dr. Seonaid Nolan is the physician lead for addiction medicine at St. Paul’s Hospital and a research scientist at the BC Centre for Excellence in HIV/AIDS. Nolan was one of 73 physicians who submitted a report to the college recommending strategies to address B.C.’s opioid abuse crisis.

The Courier spoke with Nolan about the new regulation and why the college’s decision is a significant step forward in the treatment of opioid dependence in the province.  

Why is this new shift in Suboxone treatment in B.C. so significant?

Before July 1, doctors who wanted to prescribe Suboxone for the treatment of opioid use disorder had to have a methadone licence. The new change allows doctors to prescribe Suboxone free of that licence.
We know that Suboxone is a very effective medication for the treatment of underlying opioid addiction, so the new regulation put forward by the B.C. College of Physicians and Surgeons really improves access to this safe and effective medication.

Why has it taken so long to lift this outdated restriction on Suboxone?

It’s been a historical regulation by the college to link the prescribing of all opioid agonist treatments. The recommendation on the product monograph for Suboxone doesn’t necessitate the physician’s need to have a methadone licence to prescribe it. So it’s just been a historical practice pattern that we're now re-evaluating in an attempt to improve access to this life-saving drug.  

Why is methadone the first-line medication for opioid addiction?

Methadone has been around for a lot longer than Suboxone. Suboxone was only introduced to British Columbia around 2007, so prescribers are very familiar with methadone. There’s been a lot of literature and research to evaluate methadone as a viable treatment option.

Should Suboxone replace methadone as the primary treatment for opioid addiction?

Yes, certainly. There’s a big push now because of the better safety profile to start patients on Suboxone as the first-line treatment option for opioid addiction. That being said, there should be patient involvement with regard to which medication individuals would like to start.

Methadone can be very effective for some individuals and not for others. I think there needs to be a conversation with patients who are thinking about starting opioid agonist treatment about which medication is the most suitable for them to increase their chances of success for long-term abstinence.

How does Suboxone work?

Suboxone is a partial opioid agonist. It has a superior safety profile compared to methadone, which is the medication we typically use for the treatment of opioid addiction. When Suboxone binds to the opioid receptors, it prevents the development of euphoria that individuals typically experience when they consume heroin or other opiates. We know it’s very effective in reducing the use of illicit opioids and retaining people in treatment for their underlying addiction.

Does a person have to be in moderate withdrawal to start taking Suboxone?

Yes, they do. That’s one of the difficulties in starting the medication. It’s certainly not a hurdle that can’t be overcome, but it does require some knowledge on the part of the prescribing physician. Because Suboxone is a partial opioid agonist, if there's any remaining opioids in a person's bloodstream, it will displace those opioids from the opioid receptor which can lead to withdrawal.

What are the potential drawbacks of Suboxone treatment?

I think the biggest concern is knowledge on the prescribing physician’s part with regard to precipitating withdrawal. When someone is at a point in their addiction where they're ready to seek treatment, it’s really important to capitalize on that moment. If you make them more uncomfortable during that process, then the chances of them trying to get started on Suboxone in the future can be reduced.

Another thing to mention is that although Suboxone has a better safety profile than methadone, there is an increased risk for overdose when combined with other medications such as benzodiazepine, alcohol, or other sedative drugs.

Why can’t Suboxone be used to treat an opioid overdose if it contains naloxone — a medication that blocks the effect of opioids?

Naloxone is one of the ingredients in Suboxone but the naloxone component is only added to the buprenorphine to reduce the risk of diversion [misuse]. When Suboxone is taken sublingually, the absorption of the naloxone component of the drug is negligible so it isn’t absorbed. However, if Suboxone is used illicitly, meaning it’s crushed and injected, the naloxone component is active, which precipitates withdrawal. So Suboxone is not used as a treatment for opioid overdoses.

Suboxone has been credited with reducing overdose deaths in France by 80 per cent. Can we expect similar changes in Canada?

Certainly. If more prescribers become knowledgeable and are agreeable to use Suboxone as a first-line medication for opioid addiction, then one of the major benefits is hopefully going to be a large reduction in the number of overdoses we've been seeing as of late.

How can Suboxone treatment reduce the number of overdose deaths in B.C.?

We know that about 25 percent of all prescription opioid overdoses occur among patients who are on methadone. As far as I know, there hasn’t been any evidence to suggest or demonstrate that Suboxone is associated with opioid overdose. It’s a very viable and alternative first-line treatment option that can be used to stabilize people without the risk of an overdose that does exist initially when someone is started on methadone.

What attempts are being made to create awareness about Suboxone treatment in the community?

Through the B.C. Centre for Excellence in HIV/AIDS, we have a very large knowledge translation program that is heavily involved and communicates regularly with community groups likes VANDU [Vancouver Area Network of Drug Users]. We’ve been trying to disseminate our work and advocacy for offering Suboxone through those channels. We embark on a lot of media campaigns to improve attention and awareness among members of the drug-using community.

This interview was edited and condensed.

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